I receive a lot of questions regarding when an adolescent girl should begin having a gynecologic exam. I read an recent article in the September issue of Pediatrics that reviewed the indications for performing a pelvic exam on an adolescent and when it is appropriate to have a gynecology referral.
The AAP now recommends “the inclusion of the gynecologic examination in the pediatric setting” as the primary care pediatrician is often more familiar to the adolescent than a referral to a gynecologist.
In my experience this tends to be the case as my adolescent patients seem to be “more comfortable” (if there is such a thing when discussing gynecology) seeing their own physician that they have developed a rapport with. It is much easier to discuss the “ins and outs” of a pelvic exam with a doctor that has watched you go through puberty and has hopefully educated you along the way about sexuality issues.
As with many things in medicine, things change, and this article concludes that it is no longer necessary for most adolescents to undergo a routine pelvic exam. The first Pap smear is now recommended to be performed at 21 years of age. Furthermore, an internal exam is no longer required to begin an adolescent on oral contraceptive therapy. This has just recently become the recommendation.
Now that there are screening tests for sexually transmitted infections that can be done without a speculum exam, unless the patient is having symptoms, it is not necessary to perform an internal exam.
There are times when an internal speculum exam may be necessary. Some of the indications for this include: abnormal vaginal bleeding, dysmenorrhea (menstrual cramps) which is unrelieved by treatment with non-steroidal medication such as ibuprofen or naprosyn, and persistent vaginal discharge or urinary symptoms in a sexually active adolescent. Of course pregnancy and suspected rape or sexual abuse would also require an internal pelvic examination.
The article also discusses indications for a gynecology referral from a pediatrician who may sometimes require the expertise of a gynecologist. If an adolescent have a pelvic mass, a cervical abnormality, acute pelvic pain or the need for an intrauterine device for pregnancy prevention a referral may be necessary. In this case most pediatricians have their “favorite” gynecologists to use as a referral source, as it is important to find a physician who enjoys adolescents and their special concerns and will take the needed time to explain the procedures that may be involved for further diagnosis or treatment.
The article serves to re-emphasizes the special rapport between a pediatrician and an adolescent patient, and acknowledges that most medical gynecologic issues may be managed by the pediatrician in their office as a routine part of preventative care.
Ask your pediatrician if they are comfortable addressing adolescent gynecologic issues in advance, so you will know how they will handle these issues that might crop up as your teenage daughter matures.
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